This action might not be possible to undo. Are you sure you want to continue?
Surviving on Scraps
No civil status - No medical care
Migrant workers and asylum seekers living with HIV/AIDS
A report by Physicians for Human Rights- Israel Open Clinic
Written By: Anat Aviv Research: Anat Aviv, Noa Kauffman Editing: Anat Aviv, Erela Hadar Recommendations: Ran Cohen Photo: Generation-X Translation: Shaul Vardi
Surviving on Scraps
Migrants and Asylum Seekers with HIV/AIDS, patients of Physcians for Human Rights – Israel’s Open Clinic Over the past decade, effective treatment of HIV/AIDS in the Western nations has usually consisted of a combination of drugs (the “cocktail”1) that enable carriers and patients to enjoy a normal life expectancy.2 In the countries in which the population at large enjoys accessible and readily available treatment, the diagnosis of an individual as a carrier is no longer perceived as a death sentence. Toward the end of 1997, Israel declared AIDS a chronic disease – a “serious disease” under the terms of the National Health Insurance Law – and the HMOs receive funding for drugs according to the number of registered carriers and patients.3 The treatment of HIV and AIDS has continued to improve over the years. New drugs involve fewer side effects and the method of administration is more convenient (for example, several substances are combined in a single pill). A range of therapeutic programs is available to meet the needs of patients liable to develop resistance to certain drugs.4 The Ministry of Health estimates that, as of the end of 2004, 4,230 people in Israel were living with HIV/AIDS, of whom 3,337 were reported carriers. The number of carriers and patients continues to rise, and during the period 2002-2004, an average of 320 new
Also known as Highly Active Anti-Retroviral Therapy – HAART. In North America, Western and Central Europe, the number of carriers and patients rose to 1.9 million by 2005. However, thanks to widespread access to treatment, mortality from the disease was relatively low – 30,000 patients died of AIDS in the “West” (1.57 percent). By way of comparison, in sub-Saharan Africa, the number of carriers and patients rose to 25.8 million in 2005 (approximately 60 percent of the total global number of patients and carriers). In the absence of widespread access to treatment, 2.4 million patients – children and adults – died of the disease (9.3 percent). See: http://w3.unaids.org/en/regios_countries/default.asp. The inclusion of treatment for HIV / AIDS in the health basket was preceded by a legal struggle by people living with HIV. The struggle lasted over a year following the official confirmation of the effectiveness of the treatment for AIDS at the Vancouver Conference in June 1996. Leumit HMO immediately announced that it was discontinuing the supply of the drug to those insured with the HMO, and Meuchedet and Clalit followed suit (in October 1997 and December 1997, respectively). On December 14, 1997, after a class action suit was filed by people living with HIV, the court advised the state to reach a compromise. This led to the allocation of an additional 150 million shekels for the health basket, and AIDS was declared a “serious disease” under the terms of the National Health Insurance Law, preventing the rejection of carriers by the HMOs. For a review of the history of the struggle, see the site of the Israel AIDS Task Force: http://aidsisrael.org.il. See the position paper submitted for discussion by the Drugs Basket Committee in 2006 by the Israel AIDS Task Force, on the website: http://aidsisrael.org.il/zope/home/recommendations. The Israel AIDS Task Force claims that the treatment offered in Israel to HIV/AIDS patients still lags several years behind the usual treatment in the West.
carriers and patients was reported each year.5 Mortality rates from the disease are falling: In 2003, 60 fatalities were reported from AIDS, while in 2004, according to the official figures, 20 people died of AIDS. This is a low rate (less than one percent of all carriers), reflecting the efficacy of the treatment. The picture painted above applies only to Israeli patients. We estimate that several dozen carriers and patients in Israel belong to the population of migrant workers, refugees, and asylum seekers. These individuals do not have health insurance, and their access to treatment for HIV/AIDS is far from certain. Although the health authorities clearly have an interest in ensuring that individuals who are at risk are tested and monitored,6 treatment itself is provided by the state only for pregnant women and for mothers and newborn children during the first six months following birth. By law, treatment should also be provided for prisoners and detainees in incarceration facilities, whether or not they have health insurance. In the absence of treatment by the state, a pattern has emerged over the years of attempts to treat patients on a voluntary basis, without any substantive resources. At great effort, the Israel AIDS Task Force secured the drug “cocktail,” or some of the constituent drugs, for substantial part of the patients who have asked for assistance, usually by collecting the remainders left over from Israeli patients who have switched to more advanced treatments. Hospitals forward small and restricted surpluses of the drugs to the Task
From “Periodic Report, 1981-2004, in Preparation for International AIDS Day 2005,” Department of Tuberculosis and AIDS, Ministry of Health, edited by Dr. Daniel Shem Tov: www.health,gov.il/tbaids. It may be assumed that the proportion of carriers and patients among immigrants from countries that have a high proportion of carriers among the general population, as is the case in most African countries, is similar to the proportion in their countries of origin. Many migrant workers and asylum seekers come from just these countries. Among Israeli carriers, too, there is a high proportion of individuals who originally came from countries with a high rate of infection. Of the total of 973 AIDS patients treated in Israel during the period 1981-2004, 373 came from countries with a high rate of infection by the virus among the general population. Of all the carriers registered at the end of 2004 (3,336), 1,539 came from countries where the disease is endemic. (Tables I and II, ibid.; an “endemic” rate of infection within a given population is defined by the WHO and UNAIDS as the presence of the virus in more than one percent of pregnant women). The Ministry of Health figures do not distinguish between Israelis and non-Israelis; however, we estimate, as already noted, that the number of migrant workers and refugees constitutes a small minority within this total. Dr. Motti Fried notes that, according to information from the AIDS Unit at Ichilov Hospital, some 30 percent of all the AIDS patients diagnosed at the unit in 2002 were migrant workers, most of them undocumented (see reference to his article below). However, these figures do not reflect the breakdown of new carriers at all the AIDS centers, since Ichilov treats most of the carriers who come from the migrant worker population. After the mass expulsion of migrant workers in 2003-2004, the number of new patients diagnosed in this population also seems to have fallen dramatically. In a Ministry of Health report, Dr. Shem Tov notes that in order to estimate the number of carriers living in Israel at the end of 2004, a statistical processing was undertaken “that takes into account characteristic trends of the discovery of the disease in Israel, and the massive departure from Israel of illegal aliens;” ibid.
Force, and uninsured patients have occasionally been included in clinical trials, providing a temporary supply of drugs from the companies sponsoring the research.7 Most of the diagnosed AIDS carriers among migrant workers and refugees are monitored at the AIDS centers (a minority at Kaplan, Meir, and Soroka Hospitals; probably a greater number at Hadassah Hospital; and the majority at Ichilov Hospital). The carriers are supposed to undergo periodic tests at the hospital clinics, and are referred for additional tests and given prescriptions as necessary. The drugs themselves are not provided by the hospital. Almost all the carriers and patients registered at the Open Clinic are treated under the auspices of the AIDS Center at Ichilov Hospital. After each visit to Ichilov, the attending physician provides the patient with two copies of a summary letter and hopes for the best. One copy is addressed to the Israel AIDS Task Force, accompanied when necessary by a prescription for drugs and a request to attempt to secure these, and the other is addressed to the Open Clinic, usually containing instructions to refer the patient for the next visit to the AIDS clinic, simple laboratory tests, and additional tests. Since the early days of the clinic, the organization has been able to refer patients to Ichilov, up to a certain limit of consultations and tests. We regularly use this right in order to cover physicians’ visits and simple laboratory tests for patients with HIV / AIDS. Patients who are scheduled to begin drug therapy, or who are already receiving medication, must undergo a twice-yearly evaluation of the viral load in their blood and of the condition of their immune system (viral load and CD4 tests; Israeli carriers with health insurance undergo these tests every three months) as an indication of the need for drug treatment, or of the effectiveness of this treatment if it is already being given. The cost of the tests according to the Ministry of Health pricelist is approximately NIS 2,500. The cost of the tests at Ichilov Hospital, under the terms of the special arrangement with PHR-Israel and the Israel AIDS Task Force, has been cut to half this level – NIS 1,250. 8 This is still a significant sum, and not all the patients can meet this payment on an ongoing basis, even though they are aware that the test may improve their chances of receiving the desired treatment. Their reluctance is increased by the fact that there is no automatic connection between payment for the test and actual receipt of treatment. Some patients who have dropped out of monitoring have told us that they could not afford the fees for the tests. In 2003, A. 40-year old undocumented migrant came to the clinic, accompanied by his wife and children. They reported that for several months the man had been suffering from weakness and coughs. The physician at the clinic felt that he was in a very poor
In cases when clinical trials provide the only opportunity for the participants to receive any form of treatment, the benefit accruing to the patient for the trial must be a guiding ethical principle. In accordance with the Ministry of Health regulations, drug companies running trials on new drugs must continue to supply the drug to the participants in the research for three years after its conclusion, unless it has not been proved effective. The participants in the said trials indeed continued to receive the drugs, but these periods of extension have also already expired. In the past, a further reduction was provided by the Israel AIDS Task Force through personal donations by check in the sum of NIS 500. This arrangement was halted in 2004 due to financial difficulties in the Task Force.
condition. He had a high fever, and it also emerged that he had lost weight in recent months. The man was referred to diagnosis and was found to be suffering from AIDS at an advanced stage of the disease, with cerebral infection, fungus, and other complications, as well as active tuberculosis. The patient received treatment for tuberculosis from the state9 as well as antibiotics for the infections. For approximately one year, he also received partial treatment with two anti-retroviral drugs (out of the three usually given), and his condition improved. At this stage he stopped coming for checkups, probably due to financial problems. A few months ago, A. was hospitalized again with severe anemia, fever, and coughing. He was released with a recommendation that he should be monitored closely, and, first and foremost, undergo viral load and CD4 tests. The physician noted that the last test was performed almost two years ago. Once again, the patient failed to appear for monitoring. In a telephone conversation, he explained, “I do not have a thousand shekels for tests.” The man was recently hospitalized again, and the same recommendations were given. The cost of the basic drug treatment for HIV/AIDS is at least 5,000 NIS a month – usually much more than the monthly wage of migrant workers, even those able to work on a full-time basis. For example, the cost price to the hospital of a common “cocktail” including Kaletra and Combivir is NIS 5,137.10 The price of these drugs in private pharmacies is much higher. Patients cannot cover any or all of these costs by themselves. Carriers and patients who are under monitoring also face additional expenses, such as antibiotics for preventative treatment against pneumonia, annual vaccinations against influenza and pneumonia, and inoculations against hepatitis A and B every five years. Patients with AIDS-related complications must cope with expenses for additional drugs and treatments. B., a young asylum seeker, was hospitalized at Ichilov Hospital in 2002 suffering from severe headaches and sudden partial paralysis. At the hospital, he was diagnosed as suffering from AIDS with a cerebral infection (toxoplasmosis). B. was treated in hospital and his condition improved considerably. He was then referred to the Israel AIDS Task Force for further medication. From this stage and until recently, the patient was treated with a full cocktail. His headaches and paralysis disappeared and his immune condition was reasonable. He works on a full-time basis and takes care to attend regular monitoring. A few months after he was hospitalized, B. began to suffer from a severe urological problem. He was referred to a volunteer urologist who recommended an operation. The problem is a complex one, and is not a common complication of AIDS, but it evidently developed as a result of the disease during the period when B. was in a poor state of health. Since then, B. has undergone three operations; these have helped
Treatment for tuberculosis is provided by the state for all patients, whether or not they have health insurance, through Regional Tuberculosis Treatment Centers and hospitals specializing in the disease. The major drugs manufacturers also publish substantially reduced tariffs intended for marketing some of the drugs in Third World countries only. For example, a packet of Combivir that costs an Israeli hospital NIS 2,533 is marketed by manufacturer GlaxoSmithKline at $ 19.50 to sub-Saharan countries in Africa and to a restricted list of very poor countries in Asia. See: www.gsk.com/responsibility/download.
diagnose the problem, but unfortunately have not cured it. Thanks to the arrangement with Tel Hashomer Hospital, and subsequent agreement on the part of Hadassah Hospital and the attending physician, the cost of each of the operations was calculated according to the Israeli tariff. The period of hospitalization was also minimal, out of consideration for the patient’s financial situation, since he covered most of the cost by himself. The patient is now about to undergo a fourth operation, this time at Beilinson Hospital. Again, the hospital has agreed to our request to set the price of the operation according to the Ministry of Health tariff – approximately NIS 2,700. Thanks to the provision of the cocktail by the Israel AIDS Task Force over a period of years, B. has been able to withstand all these operations and recover, despite numerous physical and emotional difficulties. The Task Force recently informed B. that due to a shortage of drugs, he will now be required to purchase one of the drugs by himself. The cost involved is thousands of shekels a month. B. is well aware that continued medication for AIDS is particularly critical at this point, before and after the operation. Despite his determination to go through with the operation, it is unclear how he will be able to bear the enormous costs involved. As explained above, the lives of uninsured people with HIV/AIDS depend on the availability of donations, particularly in the form of leftover drugs from Israeli patients, which are collected at enormous effort by the Israel AIDS Task Force. This is a piecemeal solution that by no means meets all the needs, even of those who are lucky enough to receive this assistance. This situation entails many problems: Firstly, treatment with the AIDS cocktail must be given on a regular basis and with the full combination of drugs. If this is not the case, the patient may develop partial or total resistance to the treatment, severely limiting subsequent treatment options. More advanced treatments are even more expensive, and much harder to obtain. The Israel AIDS Task Force is well aware of this problem, and attempts to address it without completely abandoning its effort to help those involved. Task Force staff emphasize that even if a patient is in a very poor condition, medication will only begin if there is a sufficient supply of drugs for at least several months, in the hope that it will later be possible, somehow or other, to continue the supply. Before treatment begins, the patient is sometimes required to undertake to purchase a particular drug if and when it is no longer regularly available, or to purchase one of the drugs, if it is not excessively expensive, as a condition for beginning medication. Several patients have met these conditions, despite the difficulties, and purchase drugs at a cost of NIS 1,000 – 2,000 a month. The Task Force does not being providing medication for new patients in cases when this might endanger the regular supply of drugs for longstanding patients. Secondly, the supply of drugs must be provided alongside regular monitoring at one of the AIDS centers in order to examine the patent’s reactions to the treatment. As noted, this involves regular visits to the attending physician and payments for periodic tests. Monitoring also includes guidance and supervision relating to healthy lifestyle and nutrition. These aspects are made clear to the patients before treatment begins, but
nevertheless there have been some patients who have failed to attend checkups or to take their medication on a regular basis; accordingly, their treatment has been discontinued. C., a 30-year old woman, came to Israel after she was persecuted by the authorities in Ethiopia. She was imprisoned pending trial in Ethiopia for several months, and was sexually and psychologically abused. She was repeatedly raped also by the men who smuggled her through Egypt to Israel. After arriving in Israel, she discovered that she has HIV and AIDS. The disease developed rapidly and C. was hospitalized at a hospital in central Israel, where she underwent tests to determine the viral load in her blood – tests she paid for in full. She received partial treatment in hospital, which she reports included two of the three drugs. She reacted badly to the drugs and, in any case, the medication was soon discontinued: she was informed in hospital that there was no way to help an uninsured patient. At this stage, C. turned to the Open Clinic and, as usual, she was referred to the AIDS Clinic at Ichilov Hospital and to the Israel AIDS Task Force. Her condition was very poor and rapidly deteriorated still further. She was unable to eat and lost a great deal of weight. Her kidney functioning was poor, her legs were swollen, and she suffered from skin sores. Despite her condition, C. struggled almost all the time to keep on working as a cleaner on a part-time basis. Her physician at Ichilov Hospital recommended that she immediately begin taking the cocktail, and warned that if she did not do so, she would not survive long. At the time, however, the Israel AIDS Task Force had run out of its supply of drugs and could not begin treating new patients. C. was put at the top of the Task Force’s waiting list, and a large supply of Kaletra, one of the drugs in the cocktail, was reserved for her. C. came to the Open Clinic almost every day, but in the absence of any treatment for AIDS, the physicians were helpless and could only offer sympathy and limited help in treating her symptoms. In an effort to assist C., we contacted the Israeli representatives of the company that manufactures Combivir, the drug missing to provide her with the cocktail. The company agreed to donate six packets of the drug – enough for six months. C. began to receive the drug cocktail and her life has been saved – for the moment. Alternative sources for AIDS drugs have recently dwindled significantly due to the small number of relevant clinical trials, if any, and the stabilization of treatment for insured Israelis on relatively good drugs that are rarely replaced. A number of patients at various stages of the disease who are awaiting treatment are not currently receiving medication. Others are obliged to purchase expensive drugs from their limited resources in an effort to continue medication. Unfortunately, many foreign citizens who are under treatment for HIV/AIDS were diagnosed when the disease was already at an advanced stage, and were referred from the clinic for urgent investigation due to their grave condition, which emerged to be a secondary infection as a result of their compromised immunity (see the case story of A.) Other patients arrived in hospital of their own initiative. We are aware of several cases in which patients have been hospitalized at a stage when their bodily systems were already gravely and irreversibly compromised. The absence of available medication did nothing to improve their chances of survival. In 2005, two patients died in hospital: both had
arrived at the emergency room with acute symptoms, and were diagnosed – in their first and last period in hospital – as suffering from HIV/AIDS at a terminal stage. In an article published in medical journal in 2003, Dr. Eyal Meltzer and Dr. Ori Elkayam describe the case of the diagnosis and treatment of a 31-year old woman, a migrant worker from Ghana, who “had no known background of illness, but who had been suffering from profound tiredness and weakness for several months.” The woman was hospitalized at Ichilov Hospital due to acute illness manifested in severe vomiting and diarrhea. She later became sleepy and confused. Following the diagnosis of a severe problem in her renal functioning, the patient was hospitalized and began dialysis. During the course of the hospitalization, it emerged that she was suffering from terminal renal failure, and HIV with a zero level of CD4 cells was diagnosed.11 The assumed diagnosis was “HIV-induced neuropathy.” However, “in a discussion with physicians from the AIDS clinic, it was recommended not to commence anti-retroviral treatment, since there was no solution for ensuring ongoing medication after her discharge from hospital – a situation that was liable to lead to the emergence of resistance [to drugs].” Meltzer and Elkayam note that in a similar case involving an Israeli citizen, a different policy was applied both in terms of the diagnosis and in terms of treatment. In an article published alongside, Dr. Moti Fried notes that “it is difficult today to find an Israeli patient suffering from AIDS who arrives at any medical facility showing such an advanced stage of the disease as in the case of the patient described here.”12 Meltzer and Elkayam conclude that “at the request of her family, the patient was discharged from hospital and returned the same day to her country, with a recommendation to continue treatment during hospitalization, provide dialysis, and commence treatment with HAART in accordance with the drugs available in her country.”13 It may not be superfluous to mention that there is no dialysis service in Ghana and the AIDS cocktail is not available in that country.14 The clinic is aware of four other patients who were diagnosed when their disease was already at a very advanced stage, and who received treatment for a limited period. All of them eventually died after great suffering.
On the basis of the latest research, the Israel AIDS Task Force recommends that antiretroviral treatment begin when the level of CD4 cells falls below 350 (the Task Force claims that a higher threshold is currently applied). See the Task Force website, ibid. Mordechai Fried, “The Attitude of the Medical System to Migrant workers in Israel, Internal Ward 10 at Sorasky Medical Center, Tel Aviv, and the Sackler Faculty of Medicine at Tel Aviv University,” Harefuah, Vol. 142, #6 (June 2003), p. 431. Eyal Meltzer and Uri Elkayam, “The Medical Treatment of Undocumented Migrant Workers in a Public Hospital: The Need for an Urgent Solution [Internal Ward 5 (Meltzer) and the Institute for Rheumatologic Diseases (Elkayam), Sorasky Medical Center, Tel Aviv and the Sackler Faculty of Medicine at Tel Aviv University,” Harefuah, Vol. 142, #6 (June 2003), from “The Case of Patient #1,” p. 402. According to UNAIDS, only a tiny percentage (1.4 percent) of patients in Ghana requiring treatment for HIV/AIDS receive treatment; see the UNAIDS site, ibid.
T., a 40-year old man, was hospitalized at Ichilov Hospital in 2001 with a tumor in the jaw. This was diagnosed as an extremely aggressive lymphoma induced by AIDS infection, with extremely grave damage to the immune system. The patient received treatment with a partial cocktail for a limited period of time, from limited reserves in the hospital, and astonishingly the tumor receded completely. The patient was unavailable for monitoring, did not receive treatment between his stays in hospital, and eventually died some eighteen months later during his third or fourth period of hospitalization. K., aged about 35, was hospitalized at Ichilov Hospital toward the end of 2000 and diagnosed with HIV/AIDS at an extremely advanced stage. He was referred to the Task Force to receive medication, and within a few months his condition improved considerably. In mid-2002, the attending physician at Ichilov wrote that the patient had stopped receiving medication and his general condition was deteriorating. The physician noted that due to the lack of funding, vital tests were not being undertaken and the patient was bound to progress to full-blown AIDS. He added that he would attempt to include the patient in treatment financed by a pharmaceutical company, but the patient would still be required to cover part of the cost of treatment. The supply of medication appears to have been resumed for a few months, but by the end of the year the files again note that K. was not receiving any treatment. In 2003, K. contracted tuberculosis and was hospitalized in isolation for treatment. After discharge, for six months he received medication for tuberculosis from the state. During the last months of his life, K. did not receive any antiretroviral treatment. He came to the clinic often, and we could only watch his condition deteriorate, unable to offer any assistance. Of the HIV/AIDS patients currently registered at the Open Clinic and at the Israel AIDS Task Force, approximately 70 percent are women.15 Almost half the women were diagnosed as carriers on arriving in hospital to give birth, or during monitoring of their pregnancy.16 Since 2002, following intervention by PHR-Israel and the Task Force, and with the support of some circles within the medical establishment, women carriers are entitled to receive anti-retroviral treatment from the state during their pregnancy, and for six months after giving birth. The medical logic behind this approach is mainly to protect the baby against infection by maintaining a low viral load in the mother. Women with HIV/AIDS are scheduled for Caesarian section in order to prevent the danger of infecting the baby during delivery. The medical condition of women who are diagnosed during the course of pregnancy, or on giving birth, is usually relatively good in terms of HIV/AIDS, if only because they were not diagnosed as the result of a specific illness. Medical monitoring in these cases may be much simpler and more effective than in the case of people at more advanced stages of the disease, due to the focus on preventing complications. However, due to the
According to Ministry of Health statistics, of 373 AIDS patients under treatment who came from countries in which the disease is endemic, 219 are men and 154 are women. Of the total of 1,539 registered carriers, 804 are women and 716 men. Ibid. Our experience shows that the Mother and Baby clinics usually advise pregnant women to undergo HIV/AIDS tests. Hospitals usually test women from populations at risk who come to give birth, so that precautions can be taken to protect the baby if necessary.
financial difficulties described above, as well as other problems relating to the nature of life asundocumented persons, experiencing persecution by the Immigration Police, these women are not always able to persevere with checkups and medication. For example, we met a woman at the clinic who told us that during the six months when she received medication for HIV/AIDS from the state, she shared this with her husband, who is also a carrier and was unable to secure treatment. Needless to say, the treatment was completely ineffective in these circumstances. L., aged 30, is an asylum seeker from a Central African country who was left on her own after all her relatives were murdered during violent disturbances in her country. She was brought to Israel by a group of pilgrims and hoped she would be able to rebuild her life here. In Tel Aviv, she married an asylum seeker from a neighboring country, became pregnant and had a son. In the maternity hospital, she learned that she was an HIV carrier. Fortunately, it emerged that her son was healthy, as was her husband. A test of L.’s viral load showed that her condition was still reasonable. She continued to work and raise her baby son. As she explained in an interview,17 she was preoccupied with daily concerns and did not even think about the disease. She did not receive any treatment at this stage. Three years later, she began to suffer from severe headaches. After hospitalization, she was found to be suffering from a cerebral infection common in HIV/AIDS. L. was treated with antibiotics and on her discharge she was told that if she wanted to stop the disease progressing, she must take medication. She states that for nine months she received the cocktail from the hospital, but was then informed that ongoing medication would require a payment of approximately NIS 2,000 a month. Since she knew that she could not possibly secure this sum, L. stopped medication. She drew comfort from the fact that she felt well, and hoped that she might be able to stay healthy if she kept a healthy diet and got rest. L. is far from relaxed, however. She still suffers from nightmares and depression as the result of her traumatic past experiences in her homeland, and she is very worried about her son and her future life in Israel. The physicians believe that L. requires medication, but in the meantime she appears to have developed a resistance to the basic treatment and will require more advanced medication that is not available to undocumented migrants. At her request, L. is receiving therapy from a volunteer psychologist at the Open Clinic. There is no doubt that even without the disease, L. would require protracted psychological support in order to cope with the horrors of her past and help her adapt to her new life. However, the proper sequence would be to treat her physical disease before embarking on psychological treatment, or at least to provide both simultaneously. The psychologist cannot save L.’s life, and L. cannot save her psychologist from a profound sense of impotence.18 Unsafe Asylum
“The State Granted Them Asylum, But Won’t Help Them Stay Alive,” Nurit Worgraft, Ha’aretz, December 1, 2005. Since the above summary was written, L. has secured temporary resident in Israel, as the mother of a child born in Israel over six years ago. Accordingly, she is entitled to health insurance, and will be able to begin to receive treatment from the date in approximately six months, after the completion of the period of qualification.
At least half of the patients currently registered at the Israel AIDS Task Force (who are receiving partial or full treatment, or awaiting treatment, or have dropped out of monitoring and treatment) are asylum seekers whose applications are pending, or people whose countries are affected by violent conflicts, regarding whom the United Nations and the State of Israel recognize that they cannot return home until the conflict ends. Their situation deserves particular attention. People from bothcategories are currently entitled to receive visas to stay in Israel, and usually to work in the country. However, contrary to the spirit of the Refugees Convention (to which Israel is party), these individuals do not receive any social rights, particularly the right to health services. The International Convention for the Protection of Refugees was first drafted in response to the horrors of the Second World War, in order to ensure protection in safe countries that signed the convention, for persons persecuted by the authorities in their own country. The State of Israel, which is in large measure a country of refugees, with a history of persecution on the grounds of religion , “race,” and nationality, should accept a particularly great moral responsibility to ensure that the convention is implemented. Israel was indeed one of the 26 countries that participated in drafting the convention and ratified it in 1951. However, with the exception of a number of well-publicized gestures to accept refugees, it was only in 2002 that Israel established a proper system to receive and examine applications for asylum. In 2003, PHR-Israel and the Refugee Rights Clinic at Tel Aviv University Law School published a report criticizing every aspect of the way asylum applications are actually processed in Israel, both relative to the Israeli current procedures for processing asylum seekers and to the procedures introduced in several European countries that have accumulated extensive experience in processing asylum seekers and refugees in light of the convention. The authors of the report presented a series of recommendations for Israeli refugee law on the basis of their examination.19 Experience to date shows that the process of examining an application for asylum in Israel can take three years or longer. During this period, the asylum seeker is entitled to protection, including, among other aspects, ensuring that they do not face hunger and that their health is not endangered due to lack of access to medical treatment. This right to protection is derived from refugee law.20 Chapter Three of the above-mentioned report offers a comparative review of the social and economic conditions provided for asylum seekers while they await a decision in their case in three European countries – Britain, Germany, and Greece.21 The review shows that, unlike Israel, these countries consider
Anat Ben Dor and Rami Adout, “The State of Israel – A Safe Haven? Problems in the Treatment of Refugees and Asylum Seekers by the State of Israel,” Report and Position Paper, Law in Service of the Community – Resource Center, Faculty of Law, Tel Aviv University, PHR-Israel, May 2003. Ibid., p. 33. A further source for the right of refugees to enjoy a basic and minimum quality of life derives from the right to dignity, which is protected in the Basic Law: Human Dignity and Liberty, and in international conventions to which Israel is party, such as the Convention on Economic, Social and Cultural Rights; ibid. Germany was chosen due to its extensive experience over the years in processing asylum seekers and refugees; Britain as a country with a legal tradition similar to Israel’s; and Greece
themselves obliged to provide minimum living conditions for asylum seekers. In particular, access to medical treatment is guaranteed. The report notes that the basket of social rights provided in these three countries is not exceptional in the context of nations that have a proper asylum system. In Germany, for example, asylum seekers undergo an initial medical examination on arriving at the centers where they live while their applications are being considered. During the first three years, they receive treatment from the state for “severe or painful” diseases, as well as psychotherapy and preventative medicine. After 36 months, asylum seekers whose cases have not yet been determined (and, of course, those who have been granted asylum) become entitled to the same medical services as citizens. In Britain, asylum seekers receive free medical services from general practitioners in their area of residence. In Greece, all asylum seekers, refugees, and individuals who are permitted to remain in the country on humanitarian grounds enjoy free access to government hospitals for the purpose of hospitalization, tests, and the receipt of medication.22 Asylum seekers face a cruel dilemma. On the one hand, they cannot return to their countries of origin, and the State of Israel recognizes this fact, to a large extent, as reflected in the serious and protracted examination of their applications. Neither can they appeal to a safe third country in which medical treatment will be forthcoming since, under the terms of the agreements between countries accepting refugees, the state in which the application for asylum is to be determined must be the first state in which such an application was filed. On the other hand, if they do not receive treatment they are liable to deteriorate and die.23 Non-Refoulement Non-refoulement is a principle in refugee law that prohibits the deportation or returning of an individual to the country of which he/she is a citizen, or to any other location in which his/her life or liberty is liable to be endangered. In certain European countries, however, (including Greece, France, and, to a large extent, Spain), the question of the treatment of foreign AIDS carriers and patients is examined not on the basis of their legal status, but in the context of public health and/or humanitarian considerations. Some countries permit the filing of an application for formal status, or for a residential and work visa, on the basis of a medical condition requiring treatment. In April 2001, PHR-Israel issued a special report in which the organization, together with the Israel AIDS Task Force, urged the health authorities to examine the positive European models in this field.24 One of the recommendations called
as a country that has only begun to develop an asylum system in recent years, and whose resources are considerably more restricted than those of other European nations absorbing refugees; ibid. Ibid., p. 49. Until recently, a small number of asylum seekers may have been able to find asylum by filing an application to emigrate to Canada, under certain conditions. However, it seems that this possibility is no longer open. Rami Adout, “Special Report on HIV and Foreigners,” April 2001. The report is available in Hebrew at the officeof PHR-Israel.
for health services and special treatment to be provided for undocumented migrants who are HIV carriers or AIDS patients, as is the practice in European countries, either by means of a humanitarian visa, if no treatment is available in the country of origin, or by means of a national treatment program with no distinction between Israeli and foreign patients. The report made particular mention of the case of Greece, a country whose resources are limited by European standards and are comparable to those of Israel, but which has applied a policy of virtual equality for HIV carriers and AIDS patients, who are entitled to full medical treatment from the state regardless of their legal status. The principle of non-refoulement, as defined at the head of this section, has extended beyond the scope of the Refugees convention, and now constitutes an integral part of international customary law.25 In 1997, on the basis of this principle, the European Court of Human Rights prohibited Britain from deporting an illegal migrant from the Caribbean islands who was an HIV carrier, on the grounds that he would face death in his country due to the lack of available treatment (UK v D., 30240/96). In 2004, PHR-Israel petitioned the Supreme Court against the deportation of two AIDS patients from Ethiopia, on the basis of the above-mentioned ruling from the European Court of Human Rights, and the professional opinion of two Israeli AIDS experts, Prof. Shlomo Maayan and Prof. Zvi Bentwich, who are familiar with the prevailing situation in Ethiopia in terms of the treatment of the disease. Their opinion clearly shows that, at present, Ethiopia does not have sufficient means to treat these patients. Two further petitions to prevent the deportation of patients on the basis of the absence of medical treatment in the countries of origin were filed in February 2005, relating to the cases of one patient from Ethiopia and one from Ghana, where access to treatment is almost nonexistent (see footnote 14 on page 8). PHR-Israel asked the court to order the state to amend its policy and to grant permits enabling foreign patients to remain in Israel for the purpose of vital treatment until such time as they can receive reasonable treatment in their own country. As a result of the petitions, the Supreme Court issued interim injunctions preventing the deportation of the appellants, pending the clarification of the state’s policy on the matter. These interim injunctions have been extended from time to time, but no policy has yet been established. In the meantime, the individuals concerned can remain in Israel and are receiving treatment. Most of them were treated under the auspices of research projects at AIDS centers, and are continuing to receive some form of treatment from the hospital. This treatment is partial and inadequate, as already described above regarding other cases. In February 2006, the coordinator of the Migrant Workers and Refugees Project in PHRIsrael contacted the Ministry of the Interior and asked that the visas of three other carriers, two from Ghana and one from Ethiopia, be extended so that they can continue treatment. The coordinator also requested that any carrier from these countries receive visas on request, at least pending the ruling in the above-mentioned petitions. The Ministry of the Interior was further asked to cooperate with the Ministry of Health in
“The State of Israel – A Safe Haven?” ibid., p. 33.
order to develop a mechanism for processing visa applications from patients from countries where AIDS treatment is known to be unavailable. Regrettably, no reply has yet been received from the Ministry of the Interior to these requests. In various European countries, the laws regarding aliens grant the authorities discretionary powers to approve visas on special grounds. For example, alien law in Sweden permits the granting of visas to persons who come from countries or regions where serious human rights violations are occurring, or to persons who are not to be returned to their own country on medical grounds, or due to other crucial personal or family considerations, and so on. In Britain, the Home Office enjoys discretion in approving visas for groups or individuals on special grounds, with very similar rights to those enjoyed by “convention refugees” and that is the case also in Greece and in Germany.26 In Israel, decisions regarding asylum seekers under the convention are made by the Consultative Committee to the Minister of the Interior. 27 The committee is also authorized to consider cases and recommend the minister to grant legal status on humanitarian grounds. Following the Supreme Court petitions filed by PHR-Israel, the Ministry of the Interior announced that criteria would be formulated for granting humanitarian status on the grounds of health. By way of a temporary procedure, the Ministry of the Interior announced that any application involving health matters will be brought for consideration before the head of the ministry’s Population Administration. In practice, no decision has yet been taken to grant status on the grounds of health, and no policy has been formulated on this matter. M., a 50-year old woman from Nigeria, arrived in Israel some ten years ago in order to make a living for her family. In 2002, she was hospitalized at Ichilov Hospital with severe pneumonia and was diagnosed as suffering from AIDS at a very advanced stage. Over the following year, she was hospitalized again for a protracted period. At the worst point she weighed just 38 kg and suffered from extensive sores due to Kaposi’s Sarcoma, a common complication in the later stages of AIDS. At the request of the attending physician from Ichilov Hospital, and with the assistance of a physician who volunteers in the clinic, a supply of thalidomide was secured for M., in place of expensive chemotherapy treatment, and the sores disappeared after protracted treatment. M. is now continuing to receive the AIDS cocktail from the Task Force and her medical condition is satisfactory. M. is present in Israel illegally. After her physical condition improved, she began to suffer from severe anxiety due to the possibility that she will be arrested and deported to her home country. Although she misses her family, she feels that deportation to Nigeria can only mean an immediate deterioration in her condition and a humiliating and agonizing death. Although Nigeria recently announced that the scope of treatment for HIV carriers and AIDS patients will be increased substantially over the coming years,28
Ibid., p. 43. This committee includes representatives of the Ministries of the Interior, Justice, and Foreign Affairs, and is empowered to decide on asylum applications after obtaining recommendations from the representative of the UN Commission for Refugees. See the procedure for the discussion of refugee applications, op. cit., Appendix A. News agencies, December 24, 2005. http://news.walla.co.il/?w=/18/830.316.
M. is convinced that she will not enjoy access to treatment, and this is probably true. We suggested that M. contact the Humanitarian Committee in the Ministry of the Interior. The physician who has treated M. over the years informed the committee that her good condition is due to the devoted treatment she has received in Israel, and that her return to Africa would lead to the cessation of treatment and to the deterioration of her medical condition, with all this implies. AIDS is a severe and chronic disease. In theory, provided treatment is available, there should be no substantive difference between AIDS patients and patients with other chronic diseases. In practice, however, carriers and patients still often suffer intense isolation due to the stigma that was attached to the disease during the protracted period when no treatment was available, and due to the infectious nature of the disease. Education and information regarding the disease, forms of treatment, and, of course, ways to avoid contracting the disease can do much to change societal attitudes toward carriers and patients and are naturally critical in terms of prevention efforts. Migrants from African and other countries in which AIDS is endemic suffer from stigmatization and social alienation no less than others, and usually more so. New carriers we meet face enormous emotional pressure due to the social exclusion they can expect to face in their immediate communities if people learn of their disease, and they do everything possible to keep this fact a secret for as long as possible. Some carriers have been treated for years by the psychiatric service in the Open Clinic, and recently a number of clients were enabled to receive ongoing psychological counseling. It must be recalled that the small, temporary communities of migrants that have developed in Tel Aviv play an important role in the survival of migrant workers in Israel. A few years ago, a volunteer from the clinic came to the assistance of a couple both of whom were carriers. The couple were about to get married, and the church they belong to had conditioned the ceremony on a detailed authorization of their state of health, including the results of a long list of infectious diseases, including HIV/AIDS. An investigation revealed that the church regularly makes this demand of people wishing to get married. In a discussion with the priest of the community (presented as a matter of generalized concern), the nature of medical confidentiality as practiced in Israel was explained, and the importance of respecting confidentiality was emphasized. The true reasons behind the demand for the health authorizations were raised, and discussion was devoted to the important role the church could play in preventing the unnecessary amplification of fear of AIDS. The couple were eventually given a very generalized authorization regarding their capacity to marry. Summary and Recommendations In our opinion, the State of Israel must accept responsibility for caring for asylum seekers and refugees, as well as for migrant workers from countries where treatment for HIV/AIDS is unavailable. It must do so in accordance with human rights considerations; in respect of the principle of non-refoulement; in order to protect the right to life and the right to live in dignity; and on humanitarian grounds.
Carriers and patients do not come to Israel with the goal of securing treatment for AIDS. They arrive because of persecution, in the case of asylum seekers, or for financial reasons, in the case of migrant workers. In those countries where the disease is endemic and treatment is unavailable, there are no active mechanisms for diagnosis. The fact that some form of treatment may be available in Israel for uninsured migrant workers is also not widely known, for the reasons discussed above. Accordingly, the argument of the danger of “medical tourism” need not be taken seriously in this case. The state should provide treatment for HIV to all who require it, on the grounds of public health, among other considerations. AIDS is an infectious disease, albeit much less so than tuberculosis and certain other sexually transmitted diseases for which the state provides universal treatment through the League for the Prevention of Lung Diseases (tuberculosis) and the Levinsky Clinic for Sexually Transmitted Diseases. It is true that treatment for HIV is much more expensive. However, every case of infection represents a tragedy for one individual and for their family, and increases the risk that the disease will be transmitted to others. Accordingly, the health authorities must make every effort to prevent the spread of the disease, particularly among populations at risk, by means of a concerted campaign to raise awareness of the methods of infection and prevention, and through the medical monitoring of new carriers. It goes without saying that unless proper treatment is guaranteed, these efforts in the migrant community are bound to be in vain. It is important to emphasize that effective and consistent treatment of carriers has tremendous significance in terms of public health, since a carrier who is receiving successful treatment is not infectious.29 As explained above, the diagnosis of HIV infection at an early stage is extremely important in medical terms, since it is then possible to treat or prevent complications and damage to body systems. Economic consideration might also be rrelevant, since it is much cheaper to treat carriers than it is to treat patients whose immune system has already been severely compromised and who have developed secondary medical problems that require expensive treatment and hospitalization. This is not the most important of arguments, however, since treatment of HIV and AIDS is always expensive, and the right to live in dignity always outweighs considerations of financial loss and gain.
In light of the above, we recommend that the following steps be taken: The State of Israel should announce that it accepts responsibility for providing medical treatment for undocumented persons in Israel whose countries of origin do not ensure available treatment for HIV/AIDS. It should do so on the
See the recommendations of the Israel AIDS Task Force to the Health Basket Committee, ibid, item 11.
grounds of human rights; the principle of non-refoulement; the right to life and the right to live in dignity; and various humanitarian considerations. The minister of health, in accordance with the authority granted in Article 56(D) of the National Health Insurance Law, 5764, should apply the National Health Insurance Law, or a similar basket of services, to the population of refugees and asylum seekers, and should enable sick people in these populations to receive proper treatment. The Ministries of the Interior and Health should develop and publish a procedure defining the criteria to be applied in granting visas and work permits for HIV carriers / AIDS patients. The procedure should take into account the country of origin of the patient and their chances of securing appropriate and accessible treatment in that country. The State of Israel and the United Nations Commission for Refugees should include a medical examination as part of the routine procedure for the submission of applications for political or humanitarian asylum in order to identify HIV carriers and AIDS patients in the initial stages of the disease, thus ensuring that they can receive proper medical treatment for their psychological and physical condition.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.